Senior Medical Director
Oregon, Utah, Idaho or Washington
The Senior Medical Director provides leadership to create and drive clinical and business strategies focused on improving clinical performance, trend management and quality throughout the health plan. This position is responsible for planning and implementation of medical policies and programs, oversight of utilization management, and support of clinical quality improvement initiatives. This role partners with leadership across the organization, including clinical services, network management, pharmacy, health informatics, actuary, product, and operations. Using data to inform actions, along with a deep understanding of clinical programs and the competitive market, this role will work collaboratively to implement and monitor effectiveness of solutions applicable to each Cambia line of business.
General Functions and Outcomes:
- Provides leadership in development and oversight of medical policies, clinical programs, and competitive strategies to improve clinical performance and achieve business objectives.
- Identify improvement opportunities and champion and drive change related to clinical outcomes, cost effectiveness and improved member experience.
- Manage assigned departments, programs, line of business or vendor partnership.
- Manage staff including hiring, training/onboarding, performance management, development and retention and may participate in talent planning discussions within Health Care Services.
- Provide internal leadership to promote medical management initiatives. Communicate in various forums as a medical and health plan subject matter expert.
- Management of high visibility escalations, executive inquires and support of applicable high-cost claimants.
- Participate in external/internal audits
- Stays abreast of Regulatory and Accreditation Standards (including ERISA standards), industry, medical and technology trends.
- Identifies and communicates new opportunities in utilization management, provider contracting or other areas that would enhance outcomes and the reputation of the organization.
Normally to be proficient in the competencies listed above:
- Physician (M.D. or D.O) with a current and unrestricted physician license in a state or territory of the United States
- Demonstrated competency working with hospitals, provider groups, or integrated delivery systems to reduce healthcare costs and improve outcomes.
- Excellent communication, influencing, presentation and facilitation skills with all levels of the organization and executive-level partners, including the ability to creatively resolve complex issues, build consensus among groups of diverse stakeholders.
- Proven ability to develop and maintain positive working relationships with provider, vendor, community, and account partners.
- In-depth knowledge of the health insurance industry, state and federal regulations, provider reimbursement methods and evolving accountable care and payment models. Proven capabilities to drive change related to population health and healthcare transformation.
- Strong knowledge of health plan clinical practices, programs, and processes, including reimbursement methodology, and benefit management.
- General business acumen including understanding of market dynamics, financial/budget management, data analysis and decision making. Expertise in applying data and best practices to manage health and quality outcomes.
- Proven ability to develop creative strategies to accomplish goals and objectives, plan and execute complex projects and programs, and drive results across internal teams and/or external partners.
- Ability to effectively manage a team and achieving results through people.
- Demonstrated ability to independently make tough strategic decisions and move forward with actions on the strategies.
- Proactive, results oriented and demonstrated ability to meet deadlines under pressure.
- Proficiency in computer use including software applications such as Microsoft Office Products, and systems used for electronic documentation of case reviews.
- Preferred experience:
- Experience developing medical policies
- Management of utilization management business function
Senior Medical Director would have a MD or DO degree (also prefer a MBA, MPH, or MHA degree), 5+ years clinical experience, plus 4+ years health plan managed care experience and leadership, sales and/or provider partnership experience, or equivalent combination of education and experience.Required Licenses, Certifications, Registration, Etc.:
Current licensed Physician with an MD or DO degree. Must have an active, unrestricted license to practice medicine in one or more states or territories of the United States. Board Certification is preferred. Qualification by training and experience to render clinical opinions about medical conditions, procedures, and treatments under review.FTEs Supervised:
- Up to 15-20 direct reports
- Work primarily performed in office environment.
- Travel required - list locally or out of state.
- May be required to work outside of normal hours.
Regence employees are part of the larger Cambia family of companies, which seeks to drive innovative health solutions. We offer a competitive salary and a generous benefits package. We are an equal opportunity employer dedicated to workforce diversity and a drug and tobacco-free workplace. All qualified applicants will receive consideration for employment without regard to race, color, national origin, religion, age, sex, sexual orientation, gender identity, disability, protected veteran status or any other status protected by law. A drug screen and background check is required.
Regence is 2.2 million members, here for our families, co-workers and neighbors, helping each other be and stay healthy and provide support in time of need. We've been here for members more than 90 years. Regence is a nonprofit health care company offering individual and group medical, dental, vision and life insurance, Medicare and other government programs as well as pharmacy benefit management. We are the largest health insurer in the Northwest/Intermountain Region, serving members as Regence BlueShield of Idaho, Regence BlueCross BlueShield of Oregon, Regence BlueCross BlueShield of Utah and Regence BlueShield (in Washington). Each plan is an independent licensee of the Blue Cross and Blue Shield Association.
If you're seeking a career that affects change in the health care system, consider joining our team at Cambia Health Solutions. We advocate for transforming the health care system by making health care more affordable and accessible, increasing consumers' engagement in their health care decisions, and offering a diverse range of products and services that promote the health and well-being of our members. Cambia's portfolio of companies spans health care information technology and software development; retail health care; health insurance plans that carry the Blue Cross and Blue Shield brands; pharmacy benefit management; life, disability, dental, vision and other lines of protection; alternative solutions to health care access and free-standing health and wellness solutions.
This position includes 401(k), healthcare, paid time off, paid holidays, and more. For more information, please visit www.cambiahealth.com/careers/total-rewards
We are an Equal Opportunity and Affirmative Action employer dedicated to workforce diversity and a drug and tobacco-free workplace. All qualified applicants will receive consideration for employment without regard to race, color, national origin, religion, age, sex, sexual orientation, gender identity, disability, protected veteran status or any other status protected by law. A drug screen and background check are required.
If you need accommodation for any part of the application process because of a medical condition or disability, please email CambiaCareers@cambiahealth.com
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